RENAL AND URETERAL CALCULUS


Stone in the kidney may remain quiescent, producing no symptoms for years. A casual inspection of the urine which proves to contain pus, would suggest an inquiry into its source. Such may be the means of detecting a silent stone. Ordinarily, however, pain referred to the involved side is an almost constant symptom, varying from a dull a loin ache to the organizing pains present, when the calculus is lodged in or traversing the ureter.


This article has been written for Dr. Clarence Barletts book, “Clinical Medicine,” which has not as yet appeared in print.- EDITOR.

Stone in the kidney may remain quiescent, producing no symptoms for years. A casual inspection of the urine which proves to contain pus, would suggest an inquiry into its source. Such may be the means of detecting a silent stone. Ordinarily, however, pain referred to the involved side is an almost constant symptom, varying from a dull a loin ache to the organizing pains present, when the calculus is lodged in or traversing the ureter.

Hematuria occurring during an attack of renal colic, or showing at times either by gross inspection or microscopically, is the next symptom of diagnostic importance. Pyuria is usually present in varying degrees. Certain reflex symptoms are present. For instance, gastro-enteric, and testicular reflexes are present. The symptoms, when associated with the others, should suggest calculus disease. Since many may be found in tuberculosis and tumor, they necessarily must be excluded.

Roentgenography is the most accurate means of determining the presence of stones in the urinary tract. The percentage of error should be very small. The density of the shadows of stones depends largely upon their chemical composition. Most calculi contain calcium, which makes them radio opaque. When a radio-opacity appears of sufficient size to suggest nephrolithiasis, localization becomes necessary.

The best method is by injecting a 17 per cent. sodium iodide solution into the ureter, which will not only show whether the stone is within the kidney pelvis, but also has the distinct advantage of showing in which part of the pelvis it is located, thus making it easy to find the stone, when pyelotomy is decided upon.

When a calcareous body is observed along the course of the ureter, before the diagnosis can be established, the opaque ureteral catheter must be introduced to localize it. This excludes the possibility of error when shadows of calcareous bodies appear upon the urogram, but are outside of the ureteral lumen.

Very few stones escape detection by pyelography or the opaque catheter. Calculi within the ureter may be detected by the wax-tip catheter, the roughened edges of the stone producing scratch marks. I have rarely used this method since it is difficult to employ when cystoscopy is conducted through a fluid medium. The condition of each kidney must be carefully inquired into.

We must have specimens from each side, carefully examined for crystals, pus, blood, casts and organisms. Not only must we have these data, but the function of each kidney as well, since calculus disease invariably diminishes renal function. It is likewise of importance to know the urine and blood picture and blood pressure. Occasionally I have found calculi in both kidneys, and sometimes calculi are found associated with renal tuberculosis.

While writing this, I have had a patient die from uremia, who had pyonephrosis due to three large stones in his left kidney and pyelonephritis, depending upon a calculus imbedded about 22 cm. above the vesical end of the right ureter. This man develops calculus anuria. He had always declined any operative interference and, as was to be expected, died from uremia despite our efforts to make the right kidney function by intravenous saline injections and attempts to remove the stone by dilatation through the renal catheter.

This man had been under my care at intervals, for two years, during which time he had suffered several attacks. In the meantime, he conducted a fairly large business, played golf, and attended somewhat to social life, this with a non-functioning left organ and a very much damaged fellow kidney. Such shows how one may live on very little functioning renal tissue for quite a time. A bright ray of hope, for those who contemplate a nephrectomy!.

Occasionally, errors in diagnosis may result by confusing a stone lodged in the ureter, with appendicitis. The differentiation is not always easy. Pain is constant in appendicitis and intermittent in calculus. Hematuria may be present in appendicitis. Renal catheterization and pyelography will usually differentiate. In the absence of renal infection, a high leucocyte count will perhaps indicate appendicitis. The general practitioner will be the one whom the patient calls to relieve the agony of an attack of renal colic.

This he may do by hypodermics of morphin, and atropin, prescribing large quantities of water to force the renal secretion. Many calculi pass through and an attack is ended for the time being. Some, however, are not so fortunate and suppression of urine seriously complaints the clinical picture. There is always a diminution in the amount of urine voided during an attack, or complete sudden suppression may result.

This condition may be due to a number of causes. A blocked ureter may cause it by reflex suppression of the activity of the fellow-kidney, or when a kidney is practically destroyed by pyonephrosis and the other kidney is toxic, or to blocking due to stone in either ureter. Radiography and ureteral catheterization will be indicated and the treatment thereby suggested. Otherwise, the patient may die from uremia. I have known an anuria to last for over 48 hours, the patient succumbing during this phase.

As soon as the condition is recognized, attempts must be made to dislodge the stone, either by surgical drainage of the kidney, its pelvis or its ureter, or through ureteral dilatation. After an attack of renal colic has subsided, either by the stone passing or slipping back into its pelvis, or even if surgical measures have been employed, then it becomes necessary to inquire into the case by means of a careful urological examination. By such, we obtain all necessary data.

The treatment for stone lodged in the kidney is surgical. This is indicated in all cases. The radiogram and pyelogram will decide the character of the operation. If one or more stones are lodged in the pelvis and cannot pass through the ureter, pyelotomy is the operation of choice, except in septic cases. The pyelotomy incision may be so enlarged that stones of considerable size may be removed. Sometimes a small incision into the renal cortex or into either pole, will be sufficient to remove a stone.

Nephrotomy, however, if extensive, is a very serious operation and subsequent to pyelotomy. It is distinctly indicated when the stones are large and of the chicken-foot type. Nephrectomy is indicated for pyonephrosis where function is practically destroyed. It may be done as a primary operation or preceded by nephrotomy. Should both kidneys be involved, I would suggest that one be operated upon first; the other, at a time when the patient has recovered from the shock of the first operation. I am opposed to simultaneous operations. Occasionally, I have made a nephrostomy.

When a stone is lodged in the ureter, its location will decide the course to follow. If located at the vesical end, an attempt may be made to dilate or incise the ureteral meatus to aid in its expulsion; or, if lodged higher up, dilatation is often successful. Where I have reason to anticipate a long cystoscopic seance, I usually ask my anesthetist to give nitrous oxide.

Special instruments have been made for extracting stones from the ureter. Sometimes they do the work, but it is always a difficult procedure. Should the operator fail to remove them, ureterotomy must be done, the incision to be made according to the location of the stone. Sometimes stones form and are passed frequently and apparently with very little distress. At the present time I have a male patient, 56 years old, who has passed many small calculi from time to time, during the past two years.

The urine is negative, except for the presence of a few pus cells, and many uric acid crystals. The blood urea is within the normal limits and the phenosulphonaphthalein function almost normal. Catheterization of the ureters shows only a few leucocytes and erythrocytes from either side. Radiography is negative and pyelography shows a normal right ureter and pelvis content of 15 cc. This is not a surgical condition, but a diathesis. Perhaps diet and water drunk liberally, may prevent larger stones from forming. Such a case should be under careful observation.

Leon T. Ashcraft